Joint dislocations for medical student
-
Upload
supatta34 -
Category
Presentations & Public Speaking
-
view
106 -
download
0
Transcript of Joint dislocations for medical student
![Page 1: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/1.jpg)
Interesting case
![Page 2: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/2.jpg)
History
Case: ผปวยชายไทย อาย 18 ป CC: ปวดหวไหลขวา 1 ชวโมง กอนมารพ. PI: 1 ชวโมงกอนมารพ . ขณะเลนฟตบอล ผปาว
ลมตวรบลกบอลไปทางดานขวา มอขวากระแทกพน หลงจากนนมอาการปวด บรเวณหวไหลขวา ขยบหวไหลไมได ยกแขนไมขน ขยบตนแขนไมได ไมไดรบบาดเจบบรเวณศรษะ ไมไดรบบาดเจบบรเวณอน
- ไมมประวตโรคประจำาตว -ไมแพยาไมแพอาหาร
![Page 3: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/3.jpg)
Physical exam
V/S T. 36 PR.68 BP. 121/60 RR.20 GA—A young Thai male,good
consciousness HEENT—Not pale conjunctivae,anicteric
sclerae Heart—Normal s1s2,no murmur Lung—Clear Abdomen—Soft,not tender Extremities—Pain at right shoulder, limit
ROM right arm and right shoulder
![Page 4: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/4.jpg)
Dugar’s sign: positive Ruler’s sign : positive
![Page 5: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/5.jpg)
![Page 6: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/6.jpg)
![Page 7: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/7.jpg)
![Page 8: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/8.jpg)
![Page 9: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/9.jpg)
Dx >> acute anterior shoulder dislocation
![Page 10: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/10.jpg)
Dislocation
Shoulder joint
![Page 11: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/11.jpg)
Glenohumeral ( Shoulder)dislocation
ขอหวไหลเปนขอทหลดบอยทสดของรางกาย เพราะโดยลกษณะ bone anatomy ทเปน large spherical humeral head articulate กบ small shallow glenoid fossa ทำาใหขอนมการเคลอนไหวคอนขางมากและหลดงาย ความมนคงของขอไหลขนกบ soft tissue ( labrum, joint capsule, surrounding muscle ) มากกวา
![Page 12: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/12.jpg)
Incidence
Shoulder is the most commonly dislocated joint
Traumatic Dislocations Anterior 95-97% Posterior 2-4%
![Page 13: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/13.jpg)
Bony Anatomy
![Page 14: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/14.jpg)
Radiographic Anatomy
![Page 15: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/15.jpg)
Stability (static and dynamic stabilizers)Static stabilizers = the bony construct and the capsulolabral
complex1. Glenohumeral joint = ball and socket joint.
Glenohumeral ligaments are lax during the mid-range of motion
and become taut at the extreme position. Glenohumeral joint capsule is a reinforced by the
glenohumeral ligaments. 2. Suction cup effect (negative intraarticular pressure) by capsule and the labrum.3. Rotator interval = capsuloligametous tissue between supraspinatus and subscapular 4.Lubricated synovial fluid.
Conditions that affect the wetability of the joint surface such as arthritis or displaced intraarticular fracture would compromise this mechanism.
Dynamic stability, the rotator cuff, the prime mover, and the periscapular muscles are the main stabilizers.
![Page 16: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/16.jpg)
Static StabilizersThe shoulder joint is composed of 4
articulationsglenohumeral, acromioclavicular,
sternoclavicular, and scapulothoracic
Instability =
![Page 17: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/17.jpg)
The Rotator Cuff Muscles
SupraspinatusInfraspinatusTeres minorSupscapularis
![Page 18: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/18.jpg)
Mechanism of injury
- anterior shoulder dislocation is usually caused by a blow to the abducted, externally rotated, and extended arm (eg, blocking a basketball shot). Less commonly, a blow to the posterior humerus or a fall on an outstretched arm may cause an anterior dislocation.- posterior shoulder dislocation A blow to the anterior portion of the shoulder, axial loading of an adducted and internally rotated arm, or violent muscle contractions following a seizure or electrocution represent the most common causes of posterior shoulder dislocation
![Page 19: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/19.jpg)
Clinical Presentation
Pain on affected side Holds the injured
limb with other hand close to the trunk
The shoulder is abducted and the elbow is kept flexed
There is loss of the normal contour of the shoulder
![Page 20: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/20.jpg)
Physical Examination
Loss of the contour of the shoulder may appear as a step
Anterior bulge of head of humerus may be visible or palpable
A gap can be palpated above the dislocated head of the humerus
![Page 21: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/21.jpg)
Physical Examination
Limited ROM Dugar’s sign Ruler’s sign
![Page 22: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/22.jpg)
Associated injuries of anterior Shoulder Dislocation Injury to the neurovascular bundle in
axilla (rare) Injury of the axillary nerve (Usually
stretching leading to temporary neurapraxia)
Associated fracture
![Page 23: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/23.jpg)
Investigations
Shoulder series AP Transcapula Transaxillary
![Page 24: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/24.jpg)
Investigations
Shoulder series AP Transcapula Transaxillary
![Page 25: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/25.jpg)
A-P: anteroposterior.
An A-P radiograph with internal rotation (A) shows the position of the greater tuberosity (arrow). With external rotation (B), the greater tuberosity becomes more obvious (arrow).
![Page 26: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/26.jpg)
Scapular (Y-view)
This radiograph utilizes a scapular Y-view of the shoulder to assess the location of the humeral head. Anterior or posterior dislocation are excluded by a normal position of the humeral head (HH) relative to the coracoid (C) and the acromion process (A). The inferior portion of the "Y" is formed by the body of the scapula (S).
![Page 27: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/27.jpg)
Axillary view
An axillary view of a normal shoulder shows the components of the shoulder including the glenoid (g), humeral head (h), coracoid process (c), clavicle (cl), lesser tuberosity (lt), acromion (a), and greater tuberosity (gt).
![Page 28: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/28.jpg)
• AP:humeral head อยใน glenoid fossa, หางจาก anteriorglenoid rim < 6 mm,
ดcortex/trabecular pattern,acromio-humeral distance 9-10 mm, calcification รอบขอหรอไม
• Lateral scapular: humeral head วางอยตรงกลาง glenoid cavity
![Page 29: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/29.jpg)
Type of Anterior Shoulder Dislocation
![Page 30: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/30.jpg)
Management
Pre-Medication
Reduction Maneuvers
Post-Reduction Immobilization
![Page 31: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/31.jpg)
Pre-Medication
Methods of Premedication prior to Reduction
None Intraarticular Lidocaine IV Sedation Supraclavicular Block Suprascapular Block
![Page 32: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/32.jpg)
Reduction technique
Stimson technique ( If the above techniques are unsuccessful )
- placing the patient prone and hanging the affected extremity off the edge of the bed with 10 to 15 pounds of weight
- Reduction is usually achieved within 30 minutes.
![Page 33: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/33.jpg)
Stimson’s Technique
![Page 34: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/34.jpg)
Reduction technique
Traction countertraction - employs a sheet wrapped under the
axilla. - While one assistant provides gentle
continuous traction at the wrist or elbow, the other provides countertraction with the sheet from the opposite side of the patient
![Page 35: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/35.jpg)
Traction Counter Traction Method
![Page 36: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/36.jpg)
Zero position technique เรมดงเบา ๆ พอใหแขนอยในทา Extend Elbow โดยไมออกแรง
ดงใหตวผปวยขยบตาม เรม Abduction ของ Shoulder ชา ๆ จนถง 90 แลวลด
ความเรวของการทา Abduction หรอหยดชวคราว เรมขยบจาก Abduction 90 จนได Full Abduction of
Shoulder (ตนแขนชดห ) สงเกตวาแขนของผปวยจะมการหมน (External rotation) ใหหมนแขนตาม (External rotation) โดยการขยบมอสองขางอยางเหมาะสม
คางแขนของผปวยไวในทา Full Abduction จนไดความรสกวาเกด Reduction หรอผปวยรสกหายจากอาการตง ๆ บรเวณไหล ใหเรมลดมม Flexion ของ Shoulder
![Page 37: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/37.jpg)
![Page 38: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/38.jpg)
FOLLOW-UP CARE - After successful reduction,shoulder is immobilized
and referred to an orthopedic surgeon within 1 week. - most common complication of shoulder dislocation
is recurrent dislocation 50 - 90 % under the age of 20
5 - 10 % over age 40 - Efforts to prevent redislocation include altering the
position of immobilization, increasing the duration of immobilization, physical therapy, and operative repair.
![Page 39: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/39.jpg)
Immobilization - The best position in which to
immobilize the shoulder after reduction remains controversial.
- We suggest immobilizing the shoulder in the traditional position of adduction and internal rotation.
- A collar and cuff, sling and swathe, or a commercially available shoulder immobilizer are equally effective.
![Page 40: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/40.jpg)
- In patients under 30 years old, the shoulder is immobilized for 3 weeks - In patients over 30 years old, the rate of redislocation is lower and early mobilization (after 1week) is needed to limit joint stiffness
-Gentle pendular motion exercises should be performed during the immobilization period to reduce the risk of frozen shoulder.
![Page 41: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/41.jpg)
- recurrent dislocation might be less likely if the shoulder were immobilized in 10 degrees of external rotation
- detachment of the glenoid labrum (ie, Bankart lesion) is the major reason for high redislocation rates among younger patients.
- If the shoulder were immobilized in external rotation, the damaged and intact parts of the glenoid labrum would lie closer to one another and be more likely to heal .
- While this theory makes intuitive sense, the evidence available from randomized trials does not demonstrate lower redislocation rates among patients immobilized in external rotation
![Page 42: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/42.jpg)
Complications
Axillary nerve injury Neurovascular injury (rare) Associated fracture of neck of
humerus or greater or lesser tuberosities
Recurrent dislocation
![Page 43: Joint dislocations for medical student](https://reader036.fdocument.pub/reader036/viewer/2022062523/58f0cd3e1a28ab80088b4629/html5/thumbnails/43.jpg)
http://www.uptodate.com/contents/shoulder-dislocation-and-reduction?source=search_result&search=reduction+shoulder+dislocation&selectedTitle=1%7E2
http://www.uptodate.com/contents/image?imageKey=EM%2F60699&topicKey=SM%2F258&rank=1%7E2&source=see_link&search=reduction+shoulder+dislocation&utdPopup=true
http://www.uptodate.com/contents/physical-examination-of-the-shoulder?source=see_link
References